Discussion

Over the course of one year, 21.5 per cent of patients who presented to the MDT were assigned to a palliative intent pathway from the outset. Exact figures for treatment intent are hard to find in the literature. One study investigating oral and oropharyngeal cancers reported that 20.8 per cent of patients were managed palliatively from the outset. Another study, also based in Glasgow, focusing on hypopharyngeal cancer, reported a similar rate of 25 per cent.^{Reference McMahon, Robertson, Liew, McManners, Mackenzie and Hislop8,Reference Pracy, Loughran, Good, Parmar and Goranova9} Age, extent of locoregional disease, metastases, co-morbidity or refusal of surgery were important determinants of palliative management. Our local rate of over one-fifth of patients being assigned to palliative intent treatment at the outset is comparable.

The most important factor in this cohort was advanced disease at diagnosis; 83 per cent of patients presented with American Joint Committee on Cancer stage IV disease. This rate is much higher than the literature would suggest.^{Reference Schenker, Arnold and Bauer1,Reference Ledeboer, van der Schroeff and Pruyn10} There may be a number of possible reasons for this advanced state at presentation. Firstly, head and neck cancer symptoms may initially be non-specific, particularly for hypopharyngeal tumours. Symptoms such as sore throat may be ignored if patients feel that it is not a worrying symptom. In recent years, there has been a big public health drive underlining that sore throats are likely to be viral, and this may be a factor in patients ignoring throat pain as a red flag symptom.¹¹ Education of the public regarding red flag symptoms may be helpful in improving earlier detection. Education of primary care clinicians may also have some benefit. Local ‘urgent suspicion of cancer’ referral guidelines to the head and neck clinic show that only a small percentage of cancers come through the urgent suspicion of cancer pathway.

Another factor in this cohort of patients may be their co-morbidities. This group of patients showed high levels of current or ex-smoking, and either current or previous alcohol excess. These factors, along with the associated co-morbidities, mean that patients are generally in a poorer overall condition, and they may seek healthcare later when curative treatment is less likely to be achieved. Additionally, a local review of head and neck cancer patients with respect to deprivation score has shown that more deprived patients present with more advanced disease.^{Reference Zeitler, Fingland, Tikka, Douglas and Montgomery12} This highlights the need for increased public education regarding the red flag symptoms, with the ultimate goal of early rather than late disease at presentation.

The three commonest reasons for a patient being assigned to palliative intent treatment at the outset when American Joint Committee on Cancer stage was less than IV were: age greater than 80 years, having a synchronous cancer and if it was deemed to be in the patient's best interests after MDT discussion.

Life expectancy is higher than ever in the UK and with that comes the burden of greater incidence of disease. However, while life expectancy rates improve overall, Glasgow has the lowest life expectancy in Scotland, with rates of 73.4 years for males and 78.9 years for females, compared to the national average of 77.4 years and 81.2 years, respectively.¹³ These important factors are likely to be associated with overall survival from head and neck cancer locally.

There has been some discussion in recent literature regarding the management of elderly patients, particularly octogenarians.^{Reference Perri, Ionna, Pavone, Longo and Caponigro14–Reference Hughley, Sperry, Thomsen, Charlton and Pagedar16} Age is not per se an exclusion criterion for primary curative treatment. Indeed, fit, elderly patients may derive a similar survival benefit as their younger counterparts.^{Reference Szturz and Vermorken15} However, higher complication rates in elderly patients and, for example, reduced survival benefit with chemotherapy, mean that treatment plans need to be carefully considered at MDT discussion.^{Reference Perri, Ionna, Pavone, Longo and Caponigro14} Decisions are made more difficult by a lack of high-quality evidence, mostly the result of an under-representation of elderly participants in studies and trials.

The commonest synchronous cancer was a lung primary in this cohort, which is unsurprising, given the high rate of smoking.

Age range was notably wide. Indeed, the youngest patient to be assigned to palliative intent at the outset was 37 years old, and this warrants further discussion. This patient's primary tumour was maxillary SCC. The patient smoked and consumed alcohol excessively, and was non-adherent with attending appointments and engaging with treatment. Curative treatment was not deemed possible after MDT discussion given the advanced tumour stage, co-morbidity and lifestyle issues.

Head and neck cancers are being seen in younger patients more frequently, particularly in males, with an increase in human papilloma virus associated cancers. It is likely that patients will continue to present in their fourth decade with head and neck cancer.^{Reference Young, Xiao, Murphy, Moore, Fakhry and Day17}

At the other end of the age range was a 96-year-old patient whose primary tumour was an oral cavity SCC. It was a T₂ stage tumour at diagnosis. The patient was deemed unfit for curative treatment in light of a poor performance status.

Mean survival time in this cohort was 151 days. This is comparable with survival findings reported in the literature.^{Reference Ledeboer, van der Schroeff and Pruyn10} Ledeboer et al. reported a slightly longer survival time of 177 days.^{Reference Ledeboer, van der Schroeff and Pruyn10} It is surprising that some patients lived with cancer for up to 18 months with a palliative diagnosis. This highlights the importance of good palliative and supportive care for patients given a terminal diagnosis. It also indicates the need for excellent communication with patients about their treatment options, as some may live for much longer than expected. It also potentially infers that the avoidance of toxic and morbid treatments may be associated with increased survival. This is one of the discussion points in Temel and colleagues’ study of patients with locally advanced non-small-cell lung cancer.^{Reference Temel, Greer, Muzikansky, Gallagher, Admane and Jackson18} Future local work aims to compare the mean survival of the palliative intent treatment patients with a curative intent treatment group.

There were a number of different palliative treatment interventions used in this cohort. Nutritional interventions were some of the commonest. Nasogastric tubes were inserted most frequently and were associated with no complications. Radiologically inserted gastrostomy tubes were made use of in four cases. This procedure is becoming more common. Although there were no complications in this cohort, there are significant potential risks with radiologically inserted gastrostomy, including perforation and abdominal sepsis. This highlights the importance of discussing both the pros and cons with patients before any intervention is undertaken. The PEG tube was only inserted in one patient, and again was associated with no complications. Of note, days in hospital were doubled for radiologically inserted gastrostomy compared to NG tube insertions. This again highlights the importance of communicating with patients about the time they may spend in hospital when undergoing an intervention. This may be an important factor to take into account for patients with a limited life expectancy.

Palliative oncological interventions were performed in some cases. Fourteen patients received radiotherapy, compared to just six who received chemotherapy. Chemotherapy was associated with almost double the number of days in hospital when compared to radiotherapy, but both treatments had similar complication rates. These data highlight the need to counsel patients regarding possible morbidities associated with interventions, particularly regarding what an intervention may mean for them in terms of days in hospital.

Surgical palliative interventions were performed fairly infrequently. Four patients had a tracheostomy (three elective and one emergency procedure). Of note, the mean number of days in hospital as a result was almost three weeks. This was a lower overall tracheostomy rate than expected.

We are interested in examining further data from recent years to identify trends in tracheostomy rate. We postulate that lower tracheostomy rates when compared to previous years may be the result of improved doctor–patient communication concerning patients’ wishes. Many patients choose not to have a tracheostomy; this preference is documented so that if they present in extremis, their wish is adhered to.

Early discussion of a patient's wishes with regard to airway emergency is crucial so that a management plan can be agreed upon. We suggest that this discussion should be approached and documented in a similar way to ‘do not resuscitate’ orders. In addition, explicit discussion with the patient and family regarding mode of death, if tracheostomy is not performed, is helpful. The use of active sedation proportional to any distress associated with dying due to airway compromise can be proposed as a management plan. If this is discussed well, it may be that death can occur peacefully, without an emergency procedure.

Debulking surgery was performed in six patients; there were no associated complications, with a mean hospital admission duration of just 1.5 days. Debulking procedures have been advocated elsewhere in the literature,^{Reference Chan, To, Wong and Wei19,Reference Paleri, Stafford and Sammut20} particularly because they often negate the need for a tracheostomy. Debulking procedures should perhaps be considered in more cases, given their favourable morbidity profile.

Interestingly, none of the palliative procedures except tracheostomy extended mean survival. This is intuitive, as the airway is protected with tracheostomy, and airway obstruction is often the final common incident when dying from head and neck cancer. However, this benefit needs to be balanced with the knowledge that a mean time of three weeks is required in hospital, which is almost one-fifth of the mean total survival time in those with a palliative diagnosis.

Of the data available, almost half of the patients died in hospital and just one-fifth died at home. These findings are similar to those of other studies, which also found that the elderly and those from more deprived areas were more likely to die in hospital.^{Reference Davies, Linklater and Jack21} Interestingly, despite more palliative care input in recent times, this has not translated into an increase in patients dying at home. However, the current orthodoxy that home is the best place of death for people has been questioned. Indeed, for patients who live alone, the lack of support at home may preclude this option altogether. Recent work in our department has shown that almost half of males with head and neck cancer live alone.^{Reference Zeitler, Fingland, Tikka, Douglas and Montgomery12} There are unique barriers to discharge from hospital in head and neck cancer cases. Managing tracheostomies and feeding tubes may pose a perceived challenge to relatively inexperienced healthcare staff and family members. One can see how home may not be the most suitable place for some patients. The aim should always be to allow the patient to die in the place of their choosing.

Based on our results, we feel it is possible to put our findings into practice and make some recommendations. In counselling patients, particularly in relation to prognosis, we can inform them that in our region, the average survival time is 151 days. Additionally, we can advise upon which interventions may take up a lesser proportion of their remaining life in hospital. The main interventions to sustain life in head and neck cancer are performed for nutrition and airway support. From this dataset, we can advise that NG tube insertion would be preferable to gastrostomy in terms of complications and time in hospital. However, there is rarely a ‘right’ choice and many patients may prefer not to have an NG tube. The right choice is the choice the patient makes, having weighed up all of the relevant information, in conjunction with the clinical team. There has been a huge effort in recent times to encourage the practice of so-called ‘realistic medicine;’²² at the heart of this philosophy is putting the patient at the centre of decisions about their healthcare.

Conversations with patients who have advanced head and neck cancer can be complex, emotive and ethically challenging, and pertain to key facets of daily life, including: speaking, breathing, eating and drinking. Having access to specialist palliative care support to guide these conversations in certain circumstances is hugely advantageous.

We suggest that airway debulking may be preferable to tracheostomy for patients who want to maximise their time outside of hospital. Airway debulking must come with the caveat that it provides only temporary airway support, but prevents an average of three weeks in hospital.

This was a descriptive study, and our results apply to a local, and likely specific, patient group. These data serve to give an indication of our own experiences in managing this difficult and poorly studied group. The authors hope that our findings may be used to inspire similar work elsewhere, and may help to inform conversations at the MDT meeting, and with patients and their families.